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Showing results for tags 'PSIRF'.
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Event
HSIB: Investigative interviewing
Patient Safety Learning posted an event in Community Calendar
This practical course offers an overview of the principles that underpin a professional safety investigation interview with either a member of staff, a patient or a family. The course aligns to the PSIRF guidance on a systems approach to interviews. The course includes: Planning and preparing for an interview Using a structured hierarchy of questions to facilitate comprehensive, accurate information Asking system-focused questions Closing an interview Register -
Content ArticleThe Patient Safety Incident Response Framework (PSIRF) supporting guidance “Engaging and involving patients, families and staff following a patient safety incident” presents the moral and logical arguments for engaging with those affected by a patient safety incident and involving them in a learning response. This article builds on the guidance given to describe how After Action Review (AAR) can be used to ensure patients and their families and carers can and do make a significant and meaningful contribution to the learning process.
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Content ArticleDespite years of calls for adoption of a Just Culture, it is evident that taking this concept from paper to practice has been slower than expected. Many have cited the subpar application of the Just Culture framework and, recently, questions have been raised regarding how the Just Culture framework is perceived by those impacted by harm, including patients, family members, and staff. Though this framework is one tool that can be used to guide inquiry after harm events, its use, independent of active efforts toward restoration of relationships with patients, families, and staff, could compromise engagement and therefore learning. A lack of focus on restoring the trust of those affected by harm in parallel with the event investigation introduces a risk of further compounding the harm for all involved. Those involved in safety work at NHS England have recognized the need to apply a systems mindset within a concerted effort toward more compassionate engagement for optimal learning and improvement. In response, they have included compassionate engagement and involvement of those affected by patient safety incidents as a foundational pillar in the NHS England Patient Safety Incident Response Framework.
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Content Article
Stephen Ashmore and Tracy Ruthven, Co-Directors of Clinical Audit Support Centre Limited, have created a simple, eye-catching poster to explain the new Patient Safety Incident Response Framework (PSIRF). Here they explain why they created the graphic. You can download the poster by clicking on the image or downloading it from the attachment at the bottom of the page.- Posted
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Content ArticleThe 'Learning Response Review and Improvement Tool' is intended to be used by: Those writing learning response reports following a patient safety incident or complaint, to inform the development of the written report. Peer reviewers of written reports to provide constructive feedback on the quality of reports and to learn from the approach of others. Development of this tool and set of standards was informed by a research study from Paul Bowie, Programme Director for Safety & Improvement at NHS Education for Scotland (NES), identified ‘traps to avoid’ in safety investigations and report writing. The tool was originally developed by NHS Scotland. It has been further refined in collaboration with HSIB and NHS England after being piloted in approximately 20 NHS trusts and healthcare organisations in England. The content validity of the tool is currently being assessed.
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Content Article
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Have you ever stopped and considered what the link is between the Patient Safety Incident Response Framework (PSIRF) and Hollywood? Probably not. Most likely, you have spent the summer of 2023 immersed in your organisation’s transition from the Serious Incident Framework (SIF) to PSIRF. Outside work, for those of us who are cinema-goers, our main Hollywood-related dilemma has revolved around which to watch first, Barbie or Oppenheimer? At the end of April 2023, we were offered the opportunity to present at the Health Care Plus conference, held at the EXCEL centre in London. Ours was the graveyard slot: Day 2 of the conference; 3.15 pm. The time when, quite understandably, the conference participants attentional capacity is usually waning. How could we encourage participants to stay the distance? How do you make a graveyard slot at the end of a two-day conference engaging? More importantly, how do you rise to that challenge when the topic is implementing PSIRF? Our solution? Bring in Hollywood. Make PSIRF glamorous. Our blog shares what we presented: ‘PSIRF: The Hollywood Edit'. Unifying key messages from NHS England’s PSIRF guidance (NHS England, August 2022) with Hollywood movie titles and a bit of what we have learnt and reflected on along the way.- Posted
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Content ArticleChris Wardley has shared his useful summary of Learn Together's '5 stage process' in involving patients and families in patient safety investigations.
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Content Article
The Response Study
Patient_Safety_Learning posted an article in Patient Safety Incident Response Framework (PSIRF)
In August 2022, NHS England launched a new way of responding to safety events, called the Patient Safety Incident Response Framework (PSIRF). The PSIRF policy aims to support NHS organisations to be more flexible in how they respond to safety events. The Response Study is funded by the National Institute for Health and Care Research (NIHR). The aim of the Response Study is to understand, in real time, how the roll out of this new policy happens across the NHS in England, and what impact it has. The study is based at the University of Leeds. It began in May 2022 and will end in July 2025. The Response Study are inviting all PSIRF Leads from NHS Trusts and Integrated Care Boards in England to complete a survey by 15 December 2023. To access the survey please contact responsestudy@leeds.ac.uk. -
Content ArticleIn rare cases, healthcare providers who have contributed to accidental patient harm may be criminally prosecuted to obtain justice for the patient and family or to set an example, which theoretically prevents other providers from making similar mistakes due to fear of punishment. This strategy was chosen in the recent case of RaDonda Vaught, who was convicted of criminally negligent homicide and impaired adult abuse after a medication error killed a patient in 2017. This article in the journal Human Factors in Healthcare discusses the case and its ramifications for healthcare staff and systems. The authors provide recommendations for actions that healthcare organisations should take to foster a safer and more resilient healthcare system, including: placing an emphasis on just culture. ensuring timely, systems-level investigations of all incidents. refining and bolstering participation in national reporting systems. incorporating Human Factors professionals at multiple levels of organisations. establishing a national safety board for medicine in the US.
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Content ArticleChris Elston, Patient Safety Education Lead, University Hospital Southampton, shares with the hub his Trust's Patient Safety Incident Response Framework (PSIRF) frequently asked questions. Please feel free to adapt and share at your own organisation.
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To mark this year’s World Patient Safety Day (WPSD), the Royal College of Surgeons of Edinburgh (RCSEd) will be running a series of blogs and Talking Heads on key surgical and dental topics in this area. These have been provided by patients, families and carers, alongside members of the College’s Patient Safety Group, College Council and the wider College fellowship. The College’s eleven Surgical Specialty Boards (SSBs) have been asked to provide blogs on how patient involvement in their individual specialty has helped to drive up standards of care. The blogs will provide examples of how patients and carers can play vital roles in making decisions about their own individual care and also how they can enhance the safety of the healthcare system as a whole by contributing to strategic decisions at organisational level. Two blogs will be released on each day of the College’s week-long WPSD campaign, starting on Monday 11 September and leading up to WPSD on Sunday 17 September. Members and Fellows will have access to these through the College website following the campaign. -
Content ArticleLearn Together is a resource website that equips patients and families with the knowledge and resources to be involved effectively in patient safety investigations. The resources have been designed, together with people who have experienced patient safety incidents and investigations, to provide the information and support patients might need following a patient safety incident. Information is provided in a range of formats including downloadable guides, videos and infographics. The site also provides information and resources for engagement leads. Learn Together is a partnership between Sheffield Hallam University, the University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford District Care NHS Foundation Trust, Leeds and York Partnership NHS Foundation Trust and York and Scarborough Teaching Hospitals NHS Foundation Trust, and is funded by the National Institute for Health and Care Research (NIHR).
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Content ArticleThis guide developed by Learn Together and Bradford Teaching Hospitals NHS Foundation Trust has been designed to help patients and families understand what to expect from patient safety investigations and how they can be involved in the process. It includes quotes and advice from patients who have been through patient safety investigations and spaces to record experiences, questions and reflections. The guide provides an outline of the investigation process, broken down into five stages: Understanding you and your needs Agreeing how you work together Giving and getting information Checking and finalising the report Next steps
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News Article
New approach to safety incidents will see fewer investigations
Patient Safety Learning posted a news article in News
Major reforms have been set out on how NHS organisations should respond to patient safety incidents, which are aimed at ensuring better engagement with patients and families. The Patient Safety Incident Response Framework (PSIRF), published today, replaces the serious incident framework and provides guidance to trusts on how and when they should conduct investigations. According to NHSE, a key aim is to allow trusts to focus resources on where investigations will have the greatest impact, rather than investigating all incidents as they did under the old framework. NHSE said the more flexible approach should make it easier to address concerns specific to health inequalities, as incidents can be learnt from that would not have met the serious incident definition. However, it does not affect the need for a patient safety incident investigation following a never event’ or maternity incident; this is still required. Helen Hughes, chief executive of charity Patient Safety Learning, said the new framework “places an emphasis on individual organisations assessing their patient safety risks”, and provided a “welcome acknowledgement of the importance of engaging patients and families as part of the investigation process”. However, she said there would need to be a “significant training programme for staff in a range of human factors informed approaches”, to ensure reviews lead to safety improvements. She added: “What is being proposed is a complex innovation in the NHS’s approach to incident investigation. Its success to a large part will depend on having the right organisational leadership and resources to support this transition. [NHSE has] now provided a set of tools and a timetable for this. However, ultimately this initiative should be judged on its implementation and effectiveness in reducing avoidable harm.” Read full story (paywalled) Source: HSJ, 16 August 202 -
Content ArticleJudy Walker talks about improving team performance through the After Action Review approach and the importance of AAR Conductor training.
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Content ArticleIn this blog, Mark Amphlett, clinical negligence specialist, looks at the recently launched Patient Safety Incident Response Framework (PSIRF), the aims of moving away from the Serious Incident Framework, and the challenges of implementation.
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Content ArticleTracey Herlihey, head of patient safety incident response policy, in the NHS England national patient safety team, is joined by Vicky Ainsworth, a communications lead at Manchester University NHS Foundation Trust and Stuart Kaill, from Health Innovation Manchester, to discuss ways of communicating about large scale change projects in NHS organisations. The podcast explores Vicky’s experience of leading on communications for a large scale change project in Manchester, with a specific focus on sharing advice and suggestions relating to communicating the changes related to the Patient Safety Incident Response Framework (PSIRF). It includes expert tips on how to communicate large scale change to different audiences as well as within both large and small organisations.
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Content ArticleIn this blog, Patient Safety Learning’s Chief Executive Helen Hughes reflects on some of the key patient safety issues and developments over the past 12 months and looks ahead to 2023.
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Content ArticlePatient safety incident investigations (PSII) are system-based responses to a patient safety incident for learning and improvement. Typically, a PSII includes four phases: planning, information gathering, synthesis, and interpreting and improving. More meaningful involvement can help reduce the risk of compounded harm for patients, families and staff, and can improve organisational learning, by listening to and valuing different perspectives.
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Content ArticleIn this episode of the What the HealthTech? podcast, Radar Healthcare's Chief Product Officer Mark Fewster speaks to Helen Hughes, Chief Executive of Patient Safety Learning. to get the lowdown on NHS England's new Patient Safety Incident Response Framework (PSIRF). Helen talks about how PSIRF is going to drive an open and just culture, what can be expected after the transition and why the implementation process is key to PSIRF's success. Listen on Spotify Listen on YouTube
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Content ArticleIn this blog, Louise Pye, Head of Family Engagement at the Healthcare Safety Investigation Branch (HSIB) highlights how the Patient Safety Incident Response Framework (PSIRF) can help NHS trusts involve patients and families in the face of extreme winter pressures. She highlights how the seven themes set out in the PSIRF guidance will help patient safety leaders ensure the involvement of patients and families is maintained even when services are dealing with extreme pressures.
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Content ArticleThis is a summary of a presentation given by NHS England's Lauren Mosley and Tracey Herlihey to discuss the Patient Safety Incident Response Framework (PSIRF) to the law firm Browne Jacobsen. The session covered key elements of PSIRF, what it means for coroners, litigation and trusts. There was also feedback from an early adopter trust,
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Megan Pontin, Patient Safety Incident Investigator at West Suffolk NHS Foundation Trust, talks about her experience as an early adopter of PSIRF. She describes the process of engaging staff, patients and families in incident investigations, and how PSIRF enables people to share what happened from their perspective. She talks about the open way in which investigation reports are compiled and reviewed to ensure everyone involved is happy with the way events are presented.
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Content ArticleThe Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. In this video, Lucy Winstanley, Head of Patient Safety and Quality at West Suffolk NHS Foundation Trust, reflects on her trust's experience of being a PSIRF early adopter. Lucy talks about the benefits of PSIRF and how to make it work in practice. She highlights the need for effective collaboration between teams and the importance of engaging with patients, families and staff in new ways.
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Content ArticleThis video offers an introduction to the Systems Engineering Initiative for Patient Safety (SEIPS) framework, an approach that looks at work systems and processes from a systems-based perspective. SEIPS is the main model used within the Patient Safety Incident Response Framework (PSIRF) adopted by the NHS. This video includes an explanation of the model and a dramatisation of the process of making a round of tea in a staff room, illustrating the error traps and design issues present in the environment.
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